Introduction
Sleeve gastrectomy (SG), which accounts for more than half of the metabolic and bariatric surgery procedures worldwide,1 is effective for weight reduction and contributes to improvement in comorbidities. However, a substantial proportion of patients experience weight regain or suboptimal clinical response over time, with weight regain rates reportedly ranging from 5.7% at 2 years to 75.6% at 6 years across systematic reviews, reflecting heterogeneity in the definitions used to identify weight regain and follow-up duration.2,3 A conversion to Roux-en-Y gastric bypass (RYGB) is often required for the management of complications, including gastroesophageal reflux disease (GERD), recurrent weight gain, strictures, or leaks.4,5 RYGB is recommended by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) for managing GERD and weight-related suboptimal clinical response after SG.6,7
In Saudi Arabia, where the prevalence of obesity exceeds 34%,8 the demand for effective revisional bariatric surgery is substantial; however, regional data on SG-to-RYGB conversion remain limited to a few Middle Eastern studies on SG-to-RYGB conversion (including randomized controlled trials)9-11 and a large global database analysis.12 The present study, with 55 participants, contributes additional regional evidence from the Middle East.
Aim
This study primarily aimed to evaluate the efficacy of conversion from SG to RYGB in achieving weight reduction and improving obesity-related comorbidities. Secondary objectives included assessing surgical indications, complication rates, GERD symptom improvement, improvement in type 2 diabetes mellitus (T2DM) and hypertension, and comparison of outcomes between laparoscopic and robotic approaches.
Materials and methods
Study design and population
We conducted a retrospective review of 55 patients who underwent conversion from SG to RYGB at a tertiary care center (King Abdulaziz University Hospital) in Saudi Arabia between January 2016 and December 2024. Eligible patients had undergone SG and were subsequently converted to RYGB for indications consistent with the ASMBS and IFSO guidelines, including GERD, recurrent weight gain (>10% from nadir), suboptimal clinical response (<20% total weight loss at 18 mo), strictures, or leaks.13 The analysis included adults (≥18 y) with a history of SG (performed at our institution or elsewhere) undergoing conversion to RYGB for an approved indication, with a minimum of 12 months of postoperative follow-up. The exclusion criteria comprised: age below 18 years, conversion to procedures other than RYGB (eg, one-anastomosis gastric bypass [OAGB] or re-SG), active malignancy, and incomplete demographic or perioperative records. Out of the 61 patients who were identified during the study period, 6 were excluded (3 were lost to follow-up before 12 months, 2 were converted to other procedures, and 1 had incomplete records), yielding a final cohort of 55 participants. A multidisciplinary team of surgeons, gastroenterologists, nutritionists, and psychologists, who assessed symptom severity, imaging findings, and lifestyle adherence, confirmed the need for conversion. Preoperative evaluation included structured assessment of GERD-related symptoms (heartburn, regurgitation, dysphagia, retrosternal chest pain, and chronic cough), nutritional status, and metabolic profile. All patients underwent routine esophagogastroduodenoscopy (EGD) for the evaluation of erosive esophagitis, hiatal hernia, and anatomical status of the previous sleeve. Cross-sectional imaging (contrast-enhanced computed tomography) was performed when leaks were suspected. Lifestyle adherence (dietary compliance and physical activity) was reviewed by a nutrition team. Erosive esophagitis severity was graded using the Los Angeles (LA) classification during EGD, ranging from grade A (mild) to D (severe), or reported as absent. The selection of surgical approach was primarily chronological, reflecting institutional adoption of technology. Surgical procedures were performed either laparoscopically (n = 40; 2016–2021) or robotically (n = 15; 2022–2024) using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, California, United States).
Surgical technique
Laparoscopic and robotic RYGB procedures followed standardized protocols. The gastric pouch was created over a 40Fr bougie using a linear stapler, measuring approximately 4–6 cm from the gastroesophageal junction, with preservation of the left gastric artery to maintain vascular supply. Laparoscopic RYGB was performed using Endo GIA linear cutting staplers (Medtronic, Minneapolis, Minnesota, United States) to construct the gastrojejunostomy, whereas robotic RYGB employed a hand-sewn gastrojejunostomy using 3–0 absorbable sutures with the da Vinci Xi Surgical System. Roux limb and biliopancreatic limb lengths were both standardized to 75–100 cm and tailored to body mass index (BMI) and metabolic requirements, with shorter limbs used in the patients with a preoperative BMI below 30 kg/m2.13 No laparoscopic-to-open surgery conversions were required. Hiatal hernias identified intraoperatively (n = 12) were repaired with primary closure using nonabsorbable sutures to restore normal anatomy and mitigate GERD symptoms.
Data collection
The collected data included: 1) patient demographics; 2) preoperative BMI before SG and before RYGB; 3) percentage of excess weight loss (%EWL), calculated as [pre-RYGB weight − 1-year post-RYGB weight]/[pre-RYGB weight − ideal weight] × 100, with ideal weight defined as BMI of 25 kg/m2; 4) percentage of total weight loss (%TWL), calculated as [pre-RYGB weight − 1-year post-RYGB weight]/[pre-RYGB weight] × 100; 5) surgical indications; 6) comorbidities (T2DM, hypertension, and GERD); 7) interval between procedures; 8) 1-year post-RYGB BMI; 9) perioperative complications (leaks, bleeding, hernias, and strictures); 10) operative time; and 11) length of hospital stay (LOS). Symptomatic GERD improvement was defined as sustained relief of reflux symptoms and discontinuation of proton pump inhibitor use. Objective endoscopic findings were available only in a subset of patients (n = 5). Follow-up data were collected during routinely scheduled postoperative clinic visits at 1, 3, 6, and 12 months postsurgery as part of our institutional bariatric protocol, as well as telephone contact and electronic medical record review when patients could not attend in person. Our cohort represents individuals who were managed within an established multidisciplinary bariatric pathway, with a strong commitment to long-term follow-up, and the patients who were lost to follow-up before 12 months were excluded a priori, which accounts for the 100% follow-up rate in the analyzed cohort. The outcomes for comorbidities were defined as the glycated hemoglobin (HbA1c) level below 6.5%, without antidiabetic medication for complete T2DM remission, and a reduction in antihypertensive medication use for hypertension improvement.
Statistical analysis
Descriptive statistics are expressed as mean (SD) and ranges. The normality of continuous variables was assessed using the Shapiro–Wilk test, and the homogeneity of variance was assessed using the Levene test. BMI, %EWL, %TWL, operative time, and LOS met the assumptions of approximate normality and equal variance within indication subgroups, supporting the use of parametric testing. Within-group BMI changes were assessed using the paired t test. One-way analysis of variance (ANOVA) with the Tukey post hoc tests were used to compare 1-year BMI and %EWL across the indication groups. Comparisons of continuous outcomes between the laparoscopic and robotic groups were performed using the independent-samples t test. Categorical outcomes were analyzed using the χ2 test or the Fisher exact test, as appropriate. Significance was set at a P value below 0.05. All statistical analyses were performed using SPSS software (version 26; IBM Corp., Armonk, New York, United States).
Ethics
The study was approved by the Institutional Review Board of King Abdulaziz University Hospital (HA-25-1-0082). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and / or national research committee and the 1964 Declaration of Helsinki and its subsequent amendments or comparable ethical standards. For this retrospective study, formal informed consent was not required; all data were obtained from archived medical records, and patient confidentiality was maintained throughout.
Results
Patient characteristics
The cohort included 55 patients (32 women and 23 men) at a mean (SD) age of 46 (8) years (range, 34–71 y), with mean (SD) pre-SG BMI of 42 (7.2) kg/m2. Indications for conversion to RYGB included GERD (n = 18), recurrent weight gain or suboptimal clinical response (n = 21), GERD and recurrent weight gain combined (n = 12), strictures (n = 2), and leaks (n = 1). Mean (SD) interval between SG and RYGB was 4.2 (2.1) years (range, 0.08–9 y). Comorbidities included T2DM (n = 26), hypertension (n = 18), and GERD (n = 39). Preoperative EGD identified erosive esophagitis severity as follows: LA grades A (n = 15), B (n = 12), C (n = 8), and D (n = 4). All 55 patients completed at least 12 months of follow-up. Patient characteristics are summarized in Table 1.
Characteristic | Value | |
|---|---|---|
Women | 32 (58.2) | |
Age, y | 46 (8) | |
Pre-SG BMI, kg/m2 | 42 (7.2) | |
Interval between SG to RYGB, y | 4.2 (2.1) | |
Comorbidities | T2DM | 26 (47.3) |
Hypertension | 18 (32.7) | |
GERD | 39 (70.9) | |
Preoperative LA grade esophagitis | A | 15 (38.5) |
B | 12 (30.8) | |
C | 8 (20.5) | |
D | 4 (10.3) | |
Indications for conversion | GERD | 18 (32.7) |
Recurrent weight gain | 21 (38.2) | |
GERD + weight gain | 12 (21.8) | |
Stricture | 2 (3.6) | |
Leak | 1 (1.8) | |
Data are presented as number (percentage) or mean (SD). Abbreviations: BMI, body mass index; GERD, gastroesophageal reflux disease; LA, Los Angeles; RYGB, Roux-en-Y gastric bypass; SG, sleeve gastrectomy; T2DM, type 2 diabetes mellitus | ||
Weight reduction outcomes
At 1 year, BMI reductions were observed in all indication groups (all P <0.001). Mean (SD) BMI decreased from 29 (2.2) to 24 (1.9) kg/m2 in the GERD group, from 44 (3.8) to 28 (3.3) kg/m2 in the recurrent weight gain group, and from 43 (3.5) to 27 (2.8) kg/m2 in the combined group. Mean (SD) %EWL was 82% (15%) in the GERD group, 65% (12%) in the recurrent weight gain group, and 67% (14%) in the combined cohort. Mean (SD) %TWL was 17% (5%) in the GERD group, 36% (8%) in the recurrent weight gain cohort, and 37% (7%) in the combined group. One-way ANOVA with Tukey post hoc tests demonstrated differences in 1-year BMI among the indication groups: the GERD group differed from the recurrent weight gain and combined groups (all post hoc P <0.001). However, no significant difference was observed between the recurrent weight gain and combined cohorts. BMI and weight loss outcomes are detailed in Tables 2 and 3, respectively.
Indication | Pre-RYGB BMI, kg/m2 | BMI at 1 year post-RYGB, kg/m2 | P value |
|---|---|---|---|
GERD (n = 18) | 29 (2.2) | 24 (1.9) | <0.001 |
Recurrent weight gain (n = 21) | 44 (3.8) | 28 (3.3) | <0.001 |
GERD + weight gain (n = 12) | 43 (3.5) | 27 (2.8) | <0.001 |
Stricture (n = 2) | 24 (3) | 26 (2) | N/A |
Leak (n = 1) | 51 | 31 | N/A |
Data are presented as mean (SD). Abbreviations: N/A, not available; others, see Table 1 | |||
Indication | %EWL | %TWL |
|---|---|---|
GERD (n = 18) | 82 (15) | 17 (5) |
Recurrent weight gain (n = 21) | 65 (12) | 36 (8) |
GERD + weight gain (n = 12) | 67 (14) | 37 (7) |
Stricture (n = 2) | N/A | N/A |
Leak (n = 1) | N/A | N/A |
Data are presented as mean (SD). Abbreviations: %EWL, percentage of excess weight loss; %TWL, percentage of total weight loss; others, see Tables 1 and 2 | ||
Resolution of comorbidities
Symptomatic GERD improvement was reported in 85% of the patients. Postoperative EGD was performed in a subset of participants (n = 5) and showed reduced erosive esophagitis severity, with 3 patients showing no esophagitis (previous LA grades A–C) and 2 with persistent grade A esophagitis (previous LA grades B–D). Therefore, the findings should be interpreted as symptom-based improvement rather than objective endoscopic resolution at the cohort level. Of the 26 patients with T2DM, 15 (58%) achieved complete remission (HbA1c <6.5%, off antidiabetic medications), and hypertension improved in 72%.
Complications
Five patients (9.1%) experienced complications: 2 leaks (3.6%), 1 gastrointestinal bleed (1.8%), 1 port-site hernia (1.8%), and 1 gastrojejunostomy stricture (1.8%). Of the 2 leaks, 1 was managed laparoscopically, whereas the other conservatively. The gastrointestinal bleed was managed laparoscopically, the gastrojejunostomy stricture was treated by endoscopic dilatation, and the port-site hernia was repaired robotically. None of the patients died during the study period. Complication rates did not differ significantly by indication (GERD group, 5.6%; recurrent weight gain group, 9.5%; and combined cohort, 8.3%; P = 0.86). Complications are summarized in Table 4.
Complication | Total | GERD | Recurrent weight gain | GERD + weight gain | P value |
|---|---|---|---|---|---|
Leaks | 2 (3.6) | 1 (5.6) | 1 (4.8) | 0 | 0.86 |
Gastrointestinal bleeding | 1 (1.8) | 0 | 1 (4.8) | 0 | |
Port-site hernia | 1 (1.8) | 0 | 0 | 1 (8.3) | |
Stricture | 1 (1.8) | 0 | 0 | 0 | |
Total | 5 (9.1) | 1 (5.6) | 2 (9.5) | 1 (8.3) | |
Data are presented as number (percentage). Abbreviations: see Table 1 | |||||
Laparoscopic vs robotic approach
Across all measured end points (including BMI reduction, %EWL, GERD symptom improvement, and complication rates), the outcomes in the laparoscopic (n = 40) and robotic groups (n = 15) were of similar magnitude. Robotic surgery was associated with longer mean (SD) operative time (172 [28] vs 158 [24] min; P = 0.04), with no significant difference in LOS. Because the laparoscopic and robotic procedures were performed in 2 distinct, nonoverlapping time periods (2016–2021 and 2022–2024), this descriptive comparison should not be interpreted as evidence of equivalence between the approaches. The results are summarized in Table 5.
Characteristic | Laparoscopic surgery (n = 40) | Robotic surgery (n = 15) | P value |
|---|---|---|---|
Operative time, min | 158 (24) | 172 (28) | 0.04 |
BMI at 1 y postsurgery, kg/m2 | 27 (4) | 26 (3) | 0.45 |
BMI reduction, kg/m2 | 14.8 (3.2) | 15.2 (2.9) | 0.67 |
%EWL | 70 (14) | 72 (13) | 0.59 |
%TWL | 30 (8) | 32 (7) | 0.6 |
Complication rate | 3 (7.5) | 2 (13.3) | 0.56 |
Length of hospital stay, d | 2.1 (0.6) | 1.8 (0.4) | 0.12 |
GERD symptom improvement | 27/32 (85) | 7/7 (95) | 0.31 |
T2DM complete remission | 11/20 (55) | 4/6 (67) | 0.62 |
Data are presented as number (percentage) or mean (SD). Abbreviations: see Tables 1 and 3 | |||
Discussion
This study demonstrates the efficacy of conversion from SG to RYGB, with significant reductions in BMI (24 to 28 kg/m2 at 1 year), improvement of GERD symptoms in 85% of the patients, complete remission of T2DM in 58% of the participants, and improvement in hypertension in 72% of the individuals, indicating outcomes consistent with the ASMBS and IFSO guidelines.6,7 These findings align with those of a recent meta-analysis reporting high GERD resolution rates (up to 99%) following conversion bariatric surgery,14 and with longitudinal data showing sustained reduction in proton pump inhibitor use after SG-to-RYGB conversion.15 The high %EWL (82%) reported in the GERD group should be interpreted with caution, as mean pre-RYGB BMI in this subgroup was only 29 kg/m2. Therefore, a modest absolute BMI reduction translates into a disproportionately large %EWL value, which may overestimate the true clinical magnitude of weight loss in this group. The corresponding %TWL (17%) is a more informative metric for this subgroup and was deliberately included to mitigate this distortion. The patients converted for recurrent weight gain or combined indications demonstrated greater absolute BMI reductions (16 to 17 kg/m2) and higher %TWL values (36%–37%).16 The overall complication rate of 9.1% is consistent with international benchmarks (5%–15%),17 regional data,8,9 and contemporary series of revisional bariatric procedures specifically performed due to complications.18 The descriptive comparison between laparoscopic and robotic approaches did not show clinically meaningful differences in the measured outcomes. However, this comparison is susceptible to chronological and learning-curve bias, and should not be interpreted as evidence of equivalence because the 2 groups were treated in nonoverlapping time periods. This interpretation aligns with 2 recent consensus statements that have framed how conversion bariatric procedures should be evaluated. The first international modified-Delphi consensus on revisional bariatric surgery, developed by an expert panel of 22 international opinion leaders,19 and the more recent 2025 Polish Expert Consensus on Metabolic and Bariatric Surgery20 emphasize that conversion procedures require standardized multidisciplinary evaluation and adequate long-term follow-up to establish durable outcomes. Our findings are broadly consistent with the literature on revisional bariatric surgery, including high-volume center experience with robotic revisional procedures.21,22
Several studies from the Middle East and the broader global literature provide important context for interpreting our findings (Table 6). Hany et al10 conducted the largest randomized controlled trial in the Middle East to date, comparing RYGB with OAGB conversion following unsuccessful SG in 160 patients, and demonstrating superior reflux resolution with RYGB. Al-Sabah et al11 from Kuwait reported that conversion bypass yielded more sustained weight-loss outcomes than re-sleeve procedures. Barajas-Gamboa et al9 from the United Arab Emirates demonstrated substantial symptom improvement but a higher perioperative risk in complex cases. Beyond the Middle East, Dang et al12 analyzed 7777 SG-to-RYGB conversions and confirmed the safety profile of the procedure. As compared with previous regional and global series,6-8,18-20 our study demonstrated similar symptomatic GERD improvement (85% vs approximately 70%) and complete T2DM remission (58% vs 38%–40%).9,10
Study | Country | Study design | Number of participants | Procedure | Key outcomes |
|---|---|---|---|---|---|
Barajas-Gamboa et al9 | United Arab Emirates | Retrospective | 47 | RYGB |
|
Al-Sabah et al11 | Kuwait | Retrospective | 84 | Re-sleeve + RYGB |
|
Hany et al10 | Egypt | RCT | 80 (RYGB arm) | RYGB vs OAGB |
|
Dang et al12 | United States | Database | 7777 | RYGB |
|
Present study | Saudi Arabia | Retrospective | 55 | RYGB |
|
Abbreviations: OAGB, one-anastomosis gastric bypass; RCT, randomized controlled trial; others, see Table 1 | |||||
Limitations
This study has several limitations. The retrospective design introduces a risk of selection bias. As a single-center study, the findings may not be generalizable to lower-volume settings. The assessment of GERD outcomes was based on subjective symptom relief without the use of standardized questionnaires, and postoperative EGD was performed only in 5 patients. The 1-year follow-up period is inadequate for evaluating long-term durability. In addition, the noncontemporaneous laparoscopic and robotic groups limit the validity of comparisons between these surgical approaches. Small subgroup sizes (strictures / leaks, n = 3; robotic, n = 15) further restrict generalizability. Future multicenter, ideally prospective, studies with larger cohorts and extended follow-up are warranted.23,24
Conclusions
Conversion to RYGB after SG is highly effective, achieving significant short-term weight loss, GERD symptom improvement, T2DM remission, and improvement in hypertension, with a low overall complication rate. Laparoscopic and robotic approaches produced descriptively similar outcomes. However, our data should be treated with caution. Prospective multicenter studies with longer follow-up are warranted to refine patient selection, technical standardization, and durability of outcomes in Middle Eastern populations.
Moaz W. Abulfaraj, MD, FRCSC, FACS, Department of Surgery, Faculty of Medicine, King Abdulaziz University, PO Box 80215, 21589 Jeddah, Saudi Arabia, phone: +966 12 640 0000, email: mabolafaraj@kau.edu.sa
May 5, 2026.
May 27, 2026.
June 24, 2026.
The authors thank the Scientific Endowment and Deanship of Scientific Research, King Abdulaziz University, Jeddah, Saudi Arabia.
The project was funded by KAU Endowment (WAQF) at King Abdulaziz University, Jeddah, Saudi Arabia. The authors, therefore, wish to thanks WAQF and the Deanship of Scientific Research for technical and financial support.
AM and MWA: study conception and design. AM: methodological revision and response to reviewers. MWA: original draft and data analysis. WJ, SK, and MA: manuscript revision and editing. All authors participated in data collection, read, and approved the final version of the manuscript.
None declared.
Artificial intelligence was not used in the preparation of this manuscript.
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